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Each person who, owing to a physical, mental, psychiatric or similar illness and regardless of their age, requires significant help and regular assistance from another person (a care professional, a relative or other private individual) to carry out basic day-to-day tasks (actes essentiels de la vie - AEV) is considered to be a dependent person.
In order to compensate the costs generated by the need for assistance and care services to carry out basic day-to-day tasks, the long-term care insurance may grant and cover the costs for the following:
- basic day-to-day tasks (AEV);
- home care services;
- activities to support an independent life;
- support activities in care facilities;
- a lump sum for incontinence products;
- assistive technologies;
- home adaptations;
- pension contributions for informal carers.
When the criteria for granting such services have been evaluated by the relevant medical specialist approved by the Administration for Evaluation and Controls (Administration d'évaluation et de contrôle - AEC), the dependent person may be granted a lump-sum cash benefit.
In order to benefit from long-term care insurance, applicants must submit their application to the National Health Fund (Caisse nationale de santé - CNS) using the specific form.
Who is concerned
Each person registered with the health insurance and their co-insured family members are entitled to long-term care insurance. Each person is entitled to long-term care insurance, regardless of income, provided they have been recognised as dependent.
Persons who take out voluntary health insurance must have been affiliated with their health insurance fund for at least one year.
Some individuals may be entitled to long-term care insurance without meeting these conditions.
These are individuals suffering from:
- hearing loss;
- decline of the eyesight;
- symptomatic forms of spina bifida;
- aphasia or dysarthria leading to impaired oral communication;
For a person who is affiliated to the National Health Fund in Luxembourg (Caisse nationale de santé) and recognised as dependent, but who does not reside in Luxembourg (for example a cross-border worker), Luxembourg covers the cash benefits. Persons concerned must address the health fund in their country of residence with respect to benefits in kind.
Persons affiliated with a health fund in another Member State of the European Union but residing in Luxembourg may be eligible for benefits in kind in Luxembourg if they are receiving treatment either in a care and assistance facility or at home if provided by an assistance and care network.
The state of dependency of children (up to age 8), is determined according to their need for additional assistance in comparison to a child of the same age who is in good health. Past 8 years of age, the tools used for the evaluation and determination of adults will be applied.
A person is deemed to be a dependent person if the following conditions are met:
- a person who, owing to a physical, mental, psychiatric or similar illness, requires significant help and regular assistance from another person to carry out basic day-to-day tasks (actes essentiels de la vie - AEV);
- basic day-to-day tasks refer to personal hygiene (e.g., bathing), assistance to go to the toilet, to eat, to dress and mobility issues;
- the level of assistance needed to carry out basic day-to-day tasks must be of a certain level and represent at least 3 ½ hours of care per week in the aforementioned areas;
- the need for assistance must be required for a minimum of 6 months or be permanent.
How to proceed
Applying for coverage
A person who wishes to benefit from long-term care insurance must submit their application for long-term care benefits by post to the National Health Fund (CNS) at the following address:
Caisse nationale de santé - Assurance dépendance
B.P. 1023 - L-1010 Luxembourg
The application consists of2 parts:
- the form to be completed by the applicant;
- the medical report (R20) attached to the second part of the form and completed free of charge by the applicant's general practitioner.
The medical report (R20) is free of charge for the applicant: the physician is paid directly by the long-term care insurance.
In this report which is for the attention of the Administration for Evaluation and Controls, the doctor provides information on the applicant's state of health. While the role of the doctor is important, they are not the ones who decide whether the person is dependent.
The application will only be considered complete when both documents (the form and the report) have been submitted to the National Health Fund (CNS).
A return receipt confirms receipt of the application.
Different types of benefits
In the case of coverage of home care, the applicant may be entitled to the following benefits:
- benefits in kind, such as aid to carry out basic day-to-day tasks, activities to support an independent life or home care services (individual care, group care, night care, training for carers, training in assistive technologies, assistance with household services) in the case where such assistance and care services are performed by a service provider;
- cash benefits which are intended for the purpose of paying the informal caregiver, and partially or fully replace the benefits in kind;
- a lump sum for incontinence products;
- assistive technology devices (for example: a wheelchair, nursing bed or walker);
- home adaptations;
- contributions to pension insurance for the caregiver, if they do not receive a personal pension (only in the cases where the dependent person is receiving care at home).
In the case of coverage of care in a facility, the applicant may be entitled to the following benefits:
- benefits in kind, such as aid to carry out basic day-to-day tasks, activities to support an independent life of the dependent person as well as support activities;
- assistive technology devices which have not yet been provided by the care facility.
Evaluation and determination of the assistance and care services required
The National Health Fund (CNS) forwards the application file to the Administration for Evaluation and Controls (AEC) of the long-term care insurance which is responsible for determining the dependence and to evaluate the level of dependence.
The evaluation of the state of dependence is performed by a health professional from the AEC, in the applicant's home, the premises of the AEC or the care and assistance facility. The applicant will be informed of the upcoming evaluation.
In principle, the health professional is responsible for the application file and also guarantees its follow up. Their contact details will be communicated to the applicant at the time of the evaluation.
During the evaluation, the dependent person's capacity to perform basic day-to-day tasks will be examined. The person applying for the benefits will be asked questions, and if needed, also a person in their close environment.
After the evaluation, the health professional draws up a summary of the assistance and care services to which the dependent person is entitled during one week, which will then allow to see if the help required reaches the minimum of 3.5 hours/week for basic day-to-day tasks (AEV).
Communication of the decision to cover care services
The President of the National Health Fund (CNS) takes the decision based on the AEC's opinion. The decision is submitted, where applicable, together with the summary of assistance and care services that will be provided. Both the dependent person and the service provider (care and assistance network or facility) will be informed of the decision.
The summary will inform the dependent person of:
- the different services to which the dependent person is entitled (basic day-to-day tasks, measures to support the person's independence, care services to keep the person at home, support activities in the care and assistance facility, lump sum to purchase incontinence products);
- the weekly amount of care and assistance services;
- a detailed description of the care and services to be provided;
- the distribution of the assistance and care services provided by the informal carer and the assistance and care network, and where applicable, the costs covered;
- assistive technology and adaptations to housing to be granted after the evaluation.
The benefits will be granted at the earliest from the day the complete application is submitted.
Revocation of benefits
If the conditions that resulted in the benefits being granted disappear, long-term care insurance benefits will be discontinued.
Benefits paid in error must be repaid, notably when the beneficiary's situation changes without the long-term care insurance management body being notified.
If the applicant does not agree with the CNS's initial decision, they may oppose it before the CNS's executive committee. To do so, they need only send a letter to the executive committee of the CNS within 40 days of the decision. The procedure is described in the decision that the person receives.
When the applicant lodges an opposition to the decision, their file is re-evaluated by the Administration for Evaluation and Controls (AEC).
If the applicant does not agree with the decision of the CNS's executive committee, they may file an appeal, within 40 days of receiving notification of the decision, with the Social Security Arbitration Tribunal (Conseil arbitral de la sécurité social - CASS) located in Luxembourg. A simple petition on plain paper submitted to the CASS will suffice.
CASS decisions can, themselves, be appealed if the amount in dispute is in excess of EUR 1,250. Applicants have to address the High Council of Social Security (Conseil supérieur de la sécurité sociale) within 40 days of the notification of each decision.
Review of the file
If the degree of required assistance and care changes, the dependent person may request that their situation be re-evaluated. The re-evaluation may also be requested by:
- family members;
- care providers;
- the CNS;
- the AEC.
In principle, a re-evaluation can only be requested one year after the last decision, except if the medical report states that there has been a fundamental change in circumstances since then.
The person submits the request for re-evaluation with the same form used to submit the initial application.
When the new evaluation gives rise to an increase in benefits, this increase will, in theory, take effect on the first day of the week in which the application was submitted. If the benefits are reduced, the reduction will be effective on the first day of the week following notification of the decision to reduce the benefits.